TRAUMA IN PREGNANCY
INTRODUCTION
Severe trauma in pregnancy is unusual at about 1.6% of pregnancies. The pregnant patient is two patients including a fetus and presents some unique issues. There are hemodynamic and respiratory differences in pregnant patients that alter their presentation in severe trauma and their treatment. Support of the mother can translate into support of the fetus.
GUIDELINES
1. Follow the XABC paradigm in evaluating a pregnant patient. Risks to pregnant patients and the fetus are more common as the uterus grows out of the protection of the bony pelvis. By 20 weeks, approaching age of viability of the fetus, the risks are much increased.
a. 20 weeks gestation can be determined by history or a palpable fundus at the level of the umbilicus in the patient’s abdomen.
2. Positioning is important. If necessary to be supine there should be Manual Left Lateral Displacement of the uterus. Consider the Left Lateral Decubitus Position if no spinal issues or for comfort.
3. Hemorrhage control (see HEMORRHAGE CONTROL protocol) is similar to non-pregnant patients.
a. Pregnant patients, depending on gestational age, are hypervolemic and have increased red blood cells causing them to maintain normal vital signs until later in hemorrhage. Observation and serial vital signs should be conducted.
b. TXA is now indicated for clinically significant non-compressible hemorrhage in pregnant patients.
i. 2 grams infused over 10 minutes within 3 hours of trauma.
4. Airway is likely to be anatomically different and more challenging for advanced airway interventions including endotracheal intubation.
a. Utilize the least invasive airway adjuncts that are effective up to endotracheal intubation.
5. Ventilation is different in pregnant patients with a respiratory alkalosis common naturally late in pregnancy.
a. Oxygen should be given to maintain pulse oximetry of about 94%. If isolated TBI aim for 100% oxygen delivery.
b. End tidal CO2 levels late in pregnancy could indicate pending respiratory failure in the high 30’s to low 40’s.
6. Circulation should be supported by judicious crystalloid fluids. Hemorrhagic hypovolemia should be managed with at least a single liter of fluid with caution after that.
a. Early transport for ER stabilization and potential blood products should be considered.
7. It is possible for late complications to develop after even minor trauma including partial or complete abruption of the placenta. Transport for monitoring is to be encouraged.
8. Traumatic cardiac arrest patients should be transported and not terminated on scene.
a. If CPR is necessary the uterus should be manually displaced from compressing the major blood vessels in the abdomen.
b. In cases of chest trauma where needle decompression is indicated insert the needle at least one interspace higher both anteriorly and laterally in late pregnancy.
INTRODUCTION
Severe trauma in pregnancy is unusual at about 1.6% of pregnancies. The pregnant patient is two patients including a fetus and presents some unique issues. There are hemodynamic and respiratory differences in pregnant patients that alter their presentation in severe trauma and their treatment. Support of the mother can translate into support of the fetus.
GUIDELINES
1. Follow the XABC paradigm in evaluating a pregnant patient. Risks to pregnant patients and the fetus are more common as the uterus grows out of the protection of the bony pelvis. By 20 weeks, approaching age of viability of the fetus, the risks are much increased.
a. 20 weeks gestation can be determined by history or a palpable fundus at the level of the umbilicus in the patient’s abdomen.
2. Positioning is important. If necessary to be supine there should be Manual Left Lateral Displacement of the uterus. Consider the Left Lateral Decubitus Position if no spinal issues or for comfort.
3. Hemorrhage control (see HEMORRHAGE CONTROL protocol) is similar to non-pregnant patients.
a. Pregnant patients, depending on gestational age, are hypervolemic and have increased red blood cells causing them to maintain normal vital signs until later in hemorrhage. Observation and serial vital signs should be conducted.
b. TXA is now indicated for clinically significant non-compressible hemorrhage in pregnant patients.
i. 2 grams infused over 10 minutes within 3 hours of trauma.
4. Airway is likely to be anatomically different and more challenging for advanced airway interventions including endotracheal intubation.
a. Utilize the least invasive airway adjuncts that are effective up to endotracheal intubation.
5. Ventilation is different in pregnant patients with a respiratory alkalosis common naturally late in pregnancy.
a. Oxygen should be given to maintain pulse oximetry of about 94%. If isolated TBI aim for 100% oxygen delivery.
b. End tidal CO2 levels late in pregnancy could indicate pending respiratory failure in the high 30’s to low 40’s.
6. Circulation should be supported by judicious crystalloid fluids. Hemorrhagic hypovolemia should be managed with at least a single liter of fluid with caution after that.
a. Early transport for ER stabilization and potential blood products should be considered.
7. It is possible for late complications to develop after even minor trauma including partial or complete abruption of the placenta. Transport for monitoring is to be encouraged.
8. Traumatic cardiac arrest patients should be transported and not terminated on scene.
a. If CPR is necessary the uterus should be manually displaced from compressing the major blood vessels in the abdomen.
b. In cases of chest trauma where needle decompression is indicated insert the needle at least one interspace higher both anteriorly and laterally in late pregnancy.